Neonatal Medicine Fetal Assessment Gestational Age Pediatrics - - PDF document

HIHIM 409 Pediatrics Fernando Vega, M.D. 1

Pediatrics

Fernando Vega, MD HIHIM 409

Neonatal Medicine

• Fetal Assessment
• Gestational Age
• –amniocentesis, c‐section, inevitable premature

delivery delivery

• LMP, quickening, first fetal heart tones,
• Physical exam,
• Ultrasound

– 1st trimester: crown‐rump – 2nd and 3rd trimester: BPD

Neonatal Medicine

• Fetal Growth
• IUGR
• Hydrocephalus
• Macrosomia

l ll b i

• Fetal well being
• Lungs
• Fetal movement
• Non stress test
• Fetal activity is accompanied by a

reflex acceleration of fetal heart rate‐ a reflex present by 32 weeks of gestation

Neonatal Medicine

• Alpha‐fetoprotein (AFP) – maternal and fetal

– Anencephaly, spina bifida – Down’s syndrome, Trisomy 13, Turner’s syndrome, Twins Twins

• Amniotic fluid: liquid and cellular elements
• Chromosomal abnormalities, f/u on 20 week labs
• Percutaneous umbilical blood sampling

Neonatal Medicine

• Timing of delivery

– Fetal well being – Maternal well being

Neonatal Medicine

• Labor and Delivery

– Stages of Labor:

• 1st ,is from onset of labor to 10 cm dilation
• 2nd,passage through the birth canal

2 ,passage through the birth canal

• 3rd,from delivery of baby to passage of placenta

– Fetal well being

• Fetal heart monitors
• Fetal scalp pH

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Neonatal Medicine Neonatal Medicine

• Physiologic changes during transition from

fetal to neonatal life.

– Expansion of lungs Air exchange – Air exchange – Termination of right to left circulatory shunt

Neonatal Medicine Neonatal Medicine

Resuscitation in the Delivery room: High risk infants that need an experienced resuscitator

• Fetal distress: abnormalities in heart rate, scalp pH<7.20
• Thick meconium in amniotic fluid
• Prematurity <36wks, postmaturity>42wks
• Low BW <2 0kg high BW >4 5kg

Low BW <2.0kg, high BW >4.5kg

• Detected congenital anomalies
• Multiple births
• Abn presentation
• Cord prolapse
• Significant vaginal bleeding
• Midforcepts delivery
• Prolonged, difficult unusual labor

Neonatal Medicine

• Respiratory distress
• Apgar score <6 at 5 minutes
• Signs of maternal infection
• Prolonged rupture
• Foul smelling amniotic fluid
• Maternal diabetes, Rh sensitization, PIH,

Neonatal Medicine

Heart Rate absent <100bpm >100 bpm Respiratory effort absent slow (irreg) Good crying

APGAR SCORE 1 2

Respiratory effort absent slow (irreg) Good crying Muscle tone Limp some flexion of extremities Active motion Reflex irritability No response Grimace Cough or snz Color Blue, Paile Pink body, blue extrmities All pink Add up five numbers to get a final score

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Neonatal Medicine

• Normal newborn
• History: family, maternal, paternal, pregnancy,

perinatal Ph i l

• Physical exam

Signs of gestational age Congenital Anomalies Successful Transition to Air breathing Impact of labor, delivery Signs of infection or metabolic diseases

Neonatal Medicine

• Caridorespiratory system: color, respiratory rate, heart

sounds, rate, pulses

• Abdomen
• GU/Rectum
• Skin
• Extremities, Spine, Joints
• Head neck mouth
• Neuro
• Neuromuscular maturity: Posture.square window,arm

recoil, popliteal angle, scarf sign, heel to ear.

• Physical maturity: skin,m lanugo, plantar creases,

breast, ear, genitals

Neonatal Medicine

• Problem newborn
• Respiratory distress
• Congenital heart disease
• Birth trauma
• Orthopedic problems
• Metabolic problems
• Hypoglycemia
• Hyperglycemia
• Dermatological problems

Neonatal Medicine

• Respiratory Tract Disorders
• Transition to Pulmonary Respiration
• Apnea
• RDS
• RDS
• TTNB
• Meconium apiration
• Pulmonary Hemorrhage
• Digestive System Disorders
• Meconium Ileus in Cystic Fibrosis

Neonatal Medicine

• Neonatal Necrotizing Enterocolitis
• Jaundice of the Newborn
• Blood Disorders
• Anemia
• Hemolytic Disease of the Newborn
• Hemorrhage in the Newborn

Infant Care

• Breast feeding, benefits
• Baby bottle tooth decay
• Solids
• Formula
• Formula
• Elimination
• Developmental Milestones
• Day/Night routine
• Child Abuse

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The Older Older Child

• Allergic Disorders
• Allergic Rhinitis
• Asthma
• Atopic Dermatitis
• Urticaria‐Angioedema
• Anaphylaxis
• Adverse reaction to Foods

Pediatric Infectious Disease

• Fever
• URI’s
• Otitis Media
• Gastroenteritis
• Pneumonia
• Menningitis
• Sepsis

Pediatric Rheumatology

• Juvenile Rheumatoid Arthritis

– Arthritis may not be evident early in the course of the disease – High fevers, rashes, markedly elevated white blood cell counts, and anemia = thought to be leukemia or Kawasaki’s

• Vasculitis

– Henoch Schoenlein Purpura – Kawasaki’s

Pediatric Oncology

– Leukemia

• White cell proliferation in blood

– Lymphoma

• White cell tumors

– Wilm’s Tumor

• Kidney malignancy

– Neuroblastoma

• Malignancy of Sympathetic ganglion cells

– Retinoblastoma

• Retina malignancy

Pediatric Nephrology

• UTI’s in children
• Evaluation of Hematuria
• Evaluation of Proteinuria

Pediatric Neurology

• Seizures in Childhood
• Febrile Seizures
• Headaches

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Febrile Seizures

• Febrile seizures are a common cause of

convulsions in young children.

• They occur in 2 to 4 percent of children

younger than five years of age but the younger than five years of age, but the incidence is as high as 15 percent in some populations.

Febrile Seizures

• A convulsion associated with an elevated

temperature greater than 38ºC A hild th i f

Criteria:

• A child younger than six years of age
• No central nervous system infection or

inflammation

• No acute systemic metabolic abnormality that

may produce convulsions

• No history of previous afebrile seizures

Febrile Seizures

• Simple febrile seizures are the most common

and are characterized by seizures that last less than 15 minutes, have no focal features, and, if they occur in a series the total duration is if they occur in a series, the total duration is less than 30 minutes.

• Complex febrile seizures are characterized by

episodes that last more than 15 minutes, have focal features or postictal paresis, and occur in a series with a total duration greater than 30 minutes

Febrile Seizures

• ETIOLOGY AND PATHOGENESIS — Febrile

seizures occur in children between the ages of six months and six years, with the majority

• ccurring in children between 12 to 18
• ccurring in children between 12 to 18

months of age. They are often seen as the temperature is increasing rapidly but may develop as the fever is declining.

Febrile Seizures

• Simple febrile seizures are the most common

type encountered in children. Generalized seizures are mainly clonic, but other forms include atonic and tonic spells include atonic and tonic spells.

• Complex febrile seizures (focal features longer

than 15 minutes or multiple episodes within 24 hours) are unusual

• An initial simple febrile seizure may be

followed by complex seizures

Febrile Seizures

• The majority of children have their febrile

seizures on the first day of illness and, in some cases, it is the first manifestation that the child is ill is ill.

• Recurrent febrile seizures do not necessarily
• ccur with the same degree of fever as the

first episode and do not occur every time the child has a fever.

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Recurring Febrile Seizures

• A major factor influencing the recurrence rate

is the age of the infant at the time of the first seizure.

• The overall recurrence rate is approximately
• The overall recurrence rate is approximately

30 to 35 percent

• 50 to 65 percent in children who are younger

than one year of age at the time of the first seizure to

• 20 percent in older children

Recurring Febrile Seizures

• Young age at onset
• History of febrile seizures in a first‐degree

relative d f f hil i h

• Low degree of fever while in the emergency

department

• Brief duration between the onset of fever and

the initial seizure

Febrile Status Epilepticus

• The median duration was 68 minutes
• The seizures were convulsive in all but one

child

Prolonged febrile seizures in 119 children, aged 1 month through 5 years:

• The seizures were continuous in 52 percent

and intermittent in 48 percent

• Two‐thirds of seizures were partial
• This was the first febrile seizure in 76 percent
• f children